The Elder Care Planning Framework

In March 2023, I was a panellist at the Ontario Bar Association’s Elder Law Day, where Dr. Richard Shulman and I spoke about decision-making capacity. In preparing our presentation, we developed this tool to aid in planning decision-making for elder care management and related financial, legal, and clinical affairs.

The management of elder care is complex and multifaceted. There are numerous intersections where care needs and decisions trigger financial and legal implications. In Canada, 73% of individuals 65 and older have at least one of ten common chronic diseases. The ten most common self-reported chronic diseases include heart disease, stroke, cancer, asthma, chronic obstructive lung disease, diabetes, arthritis, Alzheimer’s and other dementia, and mood and anxiety disorders.[1]

With the longevity revolution, more people are living longer, with rising numbers living with Alzheimer’s and other forms of dementia. This means more people than ever before are living with diminished capacity.

To further complicate matters, there is no single definition of capacity. Each case is unique and accounts for the person, the specific task, the time, and the situation the person is in. In addition, we realized that there are layers in decision-making, so we developed this elder care planning framework.

Decision-Making with the Elder Care Planning Framework

Many participants at Elder Law Day commented on the elder care planning framework. I’m more convinced than ever that we must delve more deeply into understanding decision-making as we age. Part of that is understanding the capacity a person requires to make different decisions at different times and locations. Not only do we need to know how, when, and why we will make care decisions, but anyone whom we appoint as an Attorney for Personal Care should also understand how we, as an individual, wish to make care decisions in various contexts.

Using the Elder Care Planning Framework

While it’s impossible to anticipate all care situations, the framework is a helpful structure to provide context for decision-making across the clinical, financial, and legal interfaces.

The Elder Care Planning Framework we proposed has three layers:

• Life Stages
• Decisions
• Location or setting

Care and Health Needs

Care and health needs at different stages of life stages are a continuum. We may live many years as healthy people with no chronic illness. However, most people will live with one or more chronic diseases in aging. At some point, we will probably progress to serious illness or injury and must make complex care decisions. We may recover from this stage and return to the previous stage. And then, finally, at some point, we will be at the end-of-life stage.

In each life stage, an individual will face various decisions, likely guided by the fundamental question,  what does quality of life mean to me?

• Given my changing disease circumstances, what decisions should I make about care? For example, if I have a serious illness such as metastatic cancer and the current treatments are not stopping the spread, what are my options, and how will those options affect my quality of life?
• Could I make advance care decisions so that my decisions are clear if I become seriously ill and unable to speak for myself? Who will speak for me if I don’t make advance care decisions?
• Who should I appoint as my Attorney for Personal Care, and do I know that they will follow through on my wishes?

A clinical situation may trigger the types of decisions to be made; however, it is important to remember that these decisions cannot be made in isolation as there are often financial and legal considerations.

Financial and Legal Considerations

Let’s use the example of an older person who wishes to go home alone after hip surgery. There are no rehabilitation beds available. There is no POA for Personal Care. The three adult children do not agree that the older person is safe at home alone. After some negotiation, the older person decides to use their financial resources to pay for a respite suite in a retirement home for two months. To aid in their recovery, they receive private physiotherapy at home.

Location

The location you find yourself in, for example, where you live, influences your decisions about your needs for present and future care. For example, you may be living at home with your partner, who is also your caregiver. In this setting, few professional resources may be available to recommend options and costs when your care situation changes. On the other hand, if the location is an acute care hospital, there will be numerous professional resources to help you determine your treatment and care options.

In conclusion, the management of elder care is complex. Clinical decisions will trigger different care decisions and require solutions that include financial and legal interactions. The proposed Elder Care Planning Framework is helpful for thinking about the different layers of decisions and decision-making capacity. For estate planning purposes, it is also useful for Attorneys for Personal Care to understand how the grantor has made decisions in the past.

Stay tuned for my next All About Estates blog post, where I will share more details about the decision-making process.

[1] https://www.canada.ca/en/services/health/publications/diseases-conditions/prevalence-chronic-disease-risk-factors-canadians-aged-65-years-older.html